1. The Field of the Invention
The present invention relates to systems for creating and processing health insurance claims. More particularly, the present invention relates to automated health claims processing systems, wherein a health care provider may access information relating to patients, create and submit claims electronically, learn whether the claims are to be automatically or manually adjudicated, and receive automated electronic payment from the claims processing system.
2. Relevant Technology
The cost of health care continues to increase as the health care industry becomes more complex, specialized, and sophisticated. The proportion of the gross domestic product that is accounted for by health care is expected to gradually increase over the coming years as the population ages and new medical procedures become available. Over the years, the delivery of health care services has shifted from individual physicians to large managed health maintenance organizations. This shift reflects the growing number of medical, dental, and pharmaceutical specialists in a complex variety of health care options and programs. This complexity and specialization has created large administrative systems that coordinate the delivery of health care between health care providers, administrators, patients, payors, and insurers. The cost of supporting these administrative systems has increased during recent years, thereby contributing to today""s costly health care system.
A significant portion of administrative costs is represented by the systems for reviewing and adjudicating health care provider payment requests. Such payment requests typically include bills for procedures performed and supplies given to patients. Careful review of payment requests minimizes fraud and unintentional errors and provides consistency of payment for the same treatment. However, systems for reviewing and adjudicating payment requests also represent transaction costs which directly reduce the efficiency of the health care system. Reducing the magnitude of transaction costs involved in reviewing and adjudicating payment requests would have the effect of reducing the rate of increase of health care costs. Moreover, streamlining payment request review and adjudication would also desirably increase the portion of the health care dollar that is spent on treatment rather than administration.
Several factors contribute to the traditionally high cost of health care administration, including the review and adjudication of payment requests. First, the volume of payment requests is very high. Large health management organizations may review tens of thousands of payment requests each day and tens of millions of requests yearly. In addition, the contractual obligations between parties are complex and may change frequently. Often, there are many different contractual arrangements between different patients, insurers, and health care providers. The amount of authorized payment may vary by the service or procedure, by the particular contractual arrangement with each health care provider, by the contractual arrangements between the insurer and the patient regarding the allocation of payment for treatment, and by what is considered consistent with current medical practice.
During recent years, the process of reviewing and adjudicating payment requests from health care providers has become increasingly automated. For example, there exist claims processing systems whereby technicians at health care providers"" offices electronically create and submit medical insurance claims to a central processing system. The technicians include information identifying the physician, patient, medical service, insurer, and other data with the medical insurance claim. The central processing system verifies that the physician, patient, and insurer are participants in the claims processing systems. If so, the central processing system converts the medical insurance claim into the appropriate format of the specified insurer, and the claim is then forwarded to the insurer. Upon adjudication and approval of the insurance claims, the insurer initiates an electronic fluids transfer to the physician""s account.
The foregoing example of an automated payment system reduces the amount of paperwork and time required to process insurance claims and receive payment for treatment provided to patients. However, a significant cost in processing insurance claims is the review and adjudication of individual claims. Careful review of payment requests minimizes fraud and unintentional errors and provides consistency of payment for the same treatment. Furthermore, adjudication of insurance claims ensures that the treatment for which payment is requested conforms to current medical practice and to the contractual obligations of the insurer with respect to the patient and health care provider. However, because manual review and adjudication of insurance claims is labor intensive, a large number of payment requests are simply paid to the requesting health care provider with minimal review.
There have been developed systems that partially automate the claims review and adjudication process. Under these systems, payment requests are accompanied by codified diagnostic and treatment summaries that describe the nature of the patient""s condition and the treatment provided. For example, the medical services and procedures provided to the patient may be described using the codes and code modifiers of a volume entitled Physician""s Current Procedural Terminology (CPT), which is maintained and updated annually by the American Medical Association.
When a central processing system receives codified payment requests, the system may either summarily approve the request for payment or may assign one or more review codes to the payment request, depending on the diagnosis and treatment. Review codes indicate that the payment request should be further analyzed for consistency with current medical practice or with the patient""s condition before payment is authorized. Again, depending on the nature of the treatment, payment requests that are assigned review codes may be either further processed by the automated system or may be forwarded to a medical analyst for manual adjudication.
The foregoing systems at least partially automatically adjudicate insurance claims and have the advantages of reducing the labor intensive nature of the adjudication process and reducing the amount of time needed for claims processing. However, these systems fall short of reducing or eliminating many of the aspects of the claims processing procedure that require repeated or intensive human attention. For example, from the health care provider""s standpoint, it is very difficult to routinely be aware of the medical treatments and services that are covered by each patient""s insurance plan, since different patients often have widely different contractual arrangements with insurers and health care providers. Depending on the insurance plan of each patient, the patient""s medical condition, the patient""s treatment history, and other factors, certain treatments may or may not be subject to insurance coverage.
In the past, physicians or their staff have had to spend inordinate amounts of time investigating which treatments will be covered by various insurers and insurance plans. Without detailed investigation, payment request are often rejected in full or in part for being directed to treatments not covered by a patient""s insurance plan. Furthermore, physicians are often not made aware of payment request denials until after the sometimes lengthy review and adjudication process is completed. Such delay and uncertainty frequently leads to inefficiencies in providing and selecting appropriate medical treatments and can lead to patient and health care provider frustration.
Another problem with current claims processing procedures is that health care providers are required to submit certain patient and treatment information with payment requests. This patient and treatment information may include the patient""s medical history, medical condition, and the treatment provided to the patient, along with other information that identifies the patient and gives background information. Often, different insurers and insurance plans require different sets of patient and treatment information. Accordingly, health care providers have been required to investigate the range of information required with individual patients and their associated insurers and insurance plans. Otherwise, health care providers run the risk of submitting too little information to the insurer, with the result that the payment process is delayed as the claim is returned to the health care provider and the correct information is gathered and submitted. In other situations, time and effort is wasted as patients and health care providers provide more information than is required by particular insurers.
Another problem with current systems is that when a claim is submitted for processing, the health care provider has no indication of how the claim may be processed or how the claim may be adjudicated. For example, if a particular insurer uses a combination of automated and manual adjudication procedures, there is no way for a health care provider to tell if the claim will be adjudicated manually or automatically. Furthermore, there is no way for the health care provider to determine the likelihood that a claim will be paid. In addition, since the exact amount that is ultimately paid may depend on the adjudication status of the claim, it may be difficult for a health care provider to determine the value of claims when they are submitted. Finally, since the adjudication process may take an indefinite amount of time, it is difficult to identify when payment can be expected.
Conventional claims processing systems further do not allow health care providers to adequately monitor the status of an insurance claim during the processing thereof. For example, if a submitted insurance claim has not been paid in a timely fashion, the health care provider generally has no automated system for learning of the status of the submitted claim. Typically, the only options are to personally contact a representative of the claims processing system or to merely wait for eventual payment or rejection of the submitted claim.
In view of the foregoing, there is a need in the art for more fully automated claims processing systems. For example, it would be an advancement in the art to reduce the uncertainty as to whether a claim to be submitted is likely to be paid or rejected. Furthermore, it would be advantageous to provide a claims processing system that would more easily allow health care providers to know what patient and treatment information must accompany insurance claims. There also exists a need for systems that allow health care providers to easily learn of the status of submitted insurance claims.
The present invention relates to claims processing systems that allow health care providers to electronically submit insurance claims for payment. The claims processing systems utilize network or other remote communication between computer processors, thereby increasing efficiency and decreasing the costs and time that have been associated with conventional claims processing systems.
The claims processing systems include a benefits system which allows patient to access their medical benefits information on-line, and optionally to allow authorized individuals to modify either benefit information or insurance plans when desired. Furthermore, health care providers have access to patient benefits information in preparation for consulting with a patient. Optionally, the health care provider can access, download, or print a partially prepared claim or diagnosis form having much of the patient benefits information already included thereon. Partially prepared claims forms significantly reduce overall time, effort and cost that are required to ensure that accurate and complete patient and treatment information is submitted with the insurance claims, and that the claims conform to the requirements of the insurer.
An automated adjudication system is also included in the claims processing systems of the invention. One function of the automated adjudication system is to perform a precheck process on claims before submission. When a health care provider contemplates providing treatment to a patient and submitting a claim to the patient""s insurer for payment, the precheck process may be used to determine whether the claim may be automatically adjudicated or must instead by manually adjudicated. For example, the precheck process involves comparing the diagnosis and the proposed or actual treatment against a benefits database that contains information relating to currently accepted medical practice, the contractual arrangements between the patient, the insurer, and the health care provider, and the patient""s medical history. If the precheck process indicates that a claim based on the diagnosis and proposed treatment would be automatically adjudicated, the health care provider is informed of this result. If however, the proposed claim is consistent with fraud, unintentional error, or if for some other reason the insurer would subject the claim to a more thorough review, the health care provider is informed that manual adjudication is to be conducted. In response, the health care provider may choose to modify the content of the claim in an effort to obtain automated adjudication. Feedback from the precheck process may also provide information of the amount that will be paid for the claim.
The claims precheck process significantly increases the ease by which a health care provider may submit claims that conform to accepted medical practice, the preferences of the insurer, or other standards that allow expedited review and payment of claims. The precheck process decreases the costs that have been previously associated with investigation on the part of the health care provider as to the types of treatment that would be subject to automated review and adjudication. Furthermore, the precheck process allows the health care provider to gain a more complete understanding of the status and value of the claim prior to submission.
When the health care provider is satisfied with the status of the claim, it is submitted to the adjudication system, where it is either automatically adjudicated or forwarded to a claims shop for manual review and adjudication. A payment system included in the claims processing systems of the invention initiates payment for approved claims using electronic funds transfer. In the alternative, paper checks may be used to pay the health care provider.
The claims processing systems optionally include a payment tracking system that allows health care providers to monitor the payment status of submitted claims. For example, a health care provider may remotely log on to a central system and request information relating to the review, adjudication, and payment process with respect to a particular submitted claim or patient. In response to this request, the central system retrieves the requested information and transfers the information to the health care provider. The payment tracking systems of the invention provide significant advantages over the claims processing systems that have previously been used in the art. Under the invention, health care providers have greatly improved access to the payment status of claims during the review process.
The communications infrastructure of the claims processing system may advantageously comprise the Internet. For example, the claims precheck process, claims submission, payment status tracking, and other functions whereby remote computer processors interact may be performed via the Internet. Alternatively, other wide area networks or direct dial access may be used to support the communications infrastructure of the invention.
These and other objects, features, and advantages of the present invention will become more fully apparent from the following description and appended claims, or may be learned by the practice of the invention as set forth hereinafter.